Informed consent for epidural steroid injections and diagnostic or therapeutic nerve blocks, including procedure description, risks, benefits, and alternatives.
The Epidural Steroid Injection / Nerve Block Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, pain management, epidural, nerve block, injection, interventional pain. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Epidural Steroid Injection / Nerve Block Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Provider / Practice:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Procedure Proposed **Procedure(s):** ___________ **Anatomical Level(s):** ___________ **Approach:** ___________ **Imaging Guidance:** ___________ **Planned Injectate:** ___________ **Performing Clinician:** ___________ **Facility / Location:** ___________ --- ## 2. Indication **Diagnosis / Reason for Procedure:** ___________ This procedure is recommended to address the above condition. The injection delivers corticosteroid (and/or local anesthetic) to the epidural space or around a specific nerve to reduce inflammation, interrupt pain signals, or provide diagnostic information about the pain source. ---